Oxford has released their new 2010 Advantage Three-Tier Prescription Drug List (PDL). Your pharmacy benefits offer flexibility and choice in finding the right medication for you and your family. This guide is a valuable resource in helping to understand medications and what important questions to ask the doctor or pharmacist.

WHAT THIS MEANS TO YOU AS AN EMPLOYEE?
Below is helpful information on the new PDL and understanding a three-tier system.

What is a Prescription Drug List (PDL)?
A PDL is a list that categorizes medications, products or devices that have been approved by the U.S. Food and Drug Administration (FDA) into tiers. Your pharmacy benefit provides coverage for a comprehensive selection of prescription medications. The benefit plan documents provided by your employer or health plan include a Summary Plan Description (SPD) or a Certificate of Coverage (COC) and Prescription Drug Rider. Please refer to these documents to determine which medications are covered under your plan.

Understanding Tiers
Prescription medications are categorized within three tiers. Each tier is assigned a co-payment or coinsurance, the amount you pay when you fill a prescription, which
is determined by your employer or health plan. Consult your benefit plan documents to find out the specific co-payments, coinsurance and deductibles that are part of your plan. Some plans may require you to pay the entire cost of the medication until the plan deductible has been met. Once the plan deductible has been met, your co-payment or coinsurance will apply.

Tier 1: Your lowest-cost option
Tier 1 medications are your lowest co-payment option. For the lowest out-of-pocket expense, you should always consider Tier 1 medications if you and your doctor decide they are right for your treatment.

Tier 2: Your midrange-cost option
Tier 2 medications are your middle co-payment option.

Tier 3: Your highest-cost option
Tier 3 medications are your highest co-payment option. If you are currently taking a medication in Tier 3, ask your doctor whether there are lower-cost Tier 1 or Tier 2 medications that may be right for your treatment.

Note: Compounded medications are medications with one or more ingredients that are prepared “on-site” by a pharmacist. These are classified at the Tier 3 level.

Who decides which medications get placed in which tier?
The Oxford PDL Management Committee makes tier placement decisions. The Committee’s goal is to help ensure access to a wide range of medications, while controlling health care costs for you and your employer or health plan. The PDL Management Committee comprises senior level Oxford and UnitedHealth Group physicians and business leaders. You and your doctor decide which medication is appropriate for you.

What factors do the PDL Management Committee look at to make tier placement decisions?
The PDL Management Committee decides the tier placement of a particular prescription medication based on clinical information from the Oxford Pharmacy and Therapeutics (P&T) Committee and economic considerations. The Committee looks at the overall health care value of a particular medication, balancing the need for flexibility and choice for you and an affordable pharmacy benefit for employer groups and health plans.

How often will prescription medications change tiers?
Medications may change tiers up to six times per calendar year, depending on your benefit. Most changes will occur on January 1 and July 1. Additionally, when a brand-name medication becomes available as a generic, the tier status of the brand-name medication and its corresponding generic will be evaluated. When a medication changes tiers, you may be required to pay more or less for that medication. These changes may occur without prior notice to you.

What is the difference between brand-name and generic medications?
Generic medications contain the same active ingredients as brand-name medications, but they often cost less. Generic medications become available after the patents on the brand-name medications expire. At that time, other companies are permitted to manufacture an FDA-approved, chemically equivalent medication. Many companies that make brand-name medications also produce and market generic medications. The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-tier alternative is available and if it might be appropriate for you since generic medications are typically your lowest-cost option.

Why is the medication that I am currently taking no longer covered?
Medications may be excluded from coverage under your pharmacy benefit. For example, a prescription medication may be excluded from coverage when it is therapeutically equivalent to another prescription medication or over-the-counter medication. There may be alternatives on the PDL or other over-the-counter medications that are appropriate for your treatment.

WHAT SHOULD I DO NEXT?
For more information, CLICK HERE for the 2010 Advantage Three-Tier Prescription Drug List (PDL). If you or a family member has questions about this notice please feel free to reach out to your BenefitsVIP team for assistance. As your employer’s broker, Corporate Synergies will continue to closely monitor this issue and will keep participants informed of any additional changes as they occur.

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